Provider Demographics
NPI:1770917387
Name:IVANOFF, LAUREN M (PT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:IVANOFF
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:M
Other - Last Name:BASTRIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:701 W CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6015
Mailing Address - Country:US
Mailing Address - Phone:559-713-6806
Mailing Address - Fax:559-713-6809
Practice Address - Street 1:134 S E ST
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:CA
Practice Address - Zip Code:93221-1731
Practice Address - Country:US
Practice Address - Phone:559-592-9000
Practice Address - Fax:559-592-9001
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT40515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist